Healthcare Provider Details

I. General information

NPI: 1730017245
Provider Name (Legal Business Name): JOHNATHAN SCOTT POWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 COUNTY ROAD C E
MAPLEWOOD MN
55109-9972
US

IV. Provider business mailing address

3393 NORTHDALE BLVD NW APT 309
COON RAPIDS MN
55448-1613
US

V. Phone/Fax

Practice location:
  • Phone: 651-272-4500
  • Fax:
Mailing address:
  • Phone: 859-893-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number106473
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: